Physician-level Variation Research Articles

Hospital and Physician Variability in Revascularization Decisions and Outcomes for Patients With 3-Vessel and Left Main Coronary Artery Disease: A Population-Based Cohort Study.

Hospital- and physician-level variation for selection of percutaneous coronary intervention versus coronary artery bypass grafting (CABG) for patients with coronary artery disease has been associated with outcome differences. However, most studies excluded patients treated medically. From 2010 to 2019, adults with 3-vessel or left main coronary artery disease at 3 hospitals (A, B, C) in Alberta, Canada, were categorized by treatment with medical therapy, percutaneous coronary intervention, or CABG. Multilevel regression models determined the proportion of variation in treatment attributable to patient, physician, and hospital factors, and survival models assessed outcomes including death and major adverse cardiovascular events over 5 years. Of 22 580 patients (mean age, 67 years; 80% men): 6677 (29%) received medical management, 9171 (41%) percutaneous coronary intervention, and 6732 (30%) CABG. Hospital factors accounted for 10.8% of treatment variation. In adjusted models (site A as reference), patients at sites B and C had 49% (95% CI, 44%-53%) and 43% (95% CI, 37%-49%) lower rates of medical therapy, respectively, and 31% (95% CI, 24%-38%) and 32% (95% CI, 24%-40%) lower rates of CABG. During 5.0 years median follow-up, 3287 (14.6%) patients died, with no intersite mortality differences. There were no between-site differences in acute coronary syndromes or stroke; patients at sites B and C had 24% lower risk (95% CI, 13%-34% and 11%-35%, respectively) of heart failure hospitalization. Hospital-level variation in selection of percutaneous coronary intervention, CABG, or medical therapy for patients with complex coronary artery disease was not associated with differences in 5-year mortality rates. Research and quality improvement initiatives comparing revascularization practices should include medically managed patients.

Between-hospital variation in indicators of quality of care: a systematic review

BackgroundEfforts to mitigate unwarranted variation in the quality of care require insight into the ‘level’ (eg, patient, physician, ward, hospital) at which observed variation exists. This systematic literature review aims...

Abstract 4846: Geographic and physician-level variation in the use of hypofractionated radiotherapy for breast cancer in the U.S.: A cross-classified multilevel analysis

Abstract Hypofractionated whole-breast irradiation (HF-WBI), a radiotherapy with a larger dose per fraction and a shorter schedule for early-stage breast cancer patients post breast-conserving surgery, shows equivalent safety and efficacy compared to conventionally fractionated whole-breast irradiation (CF-WBI) regarding local recurrence and disease-free survival. While several countries have set HF-WBI as the preferred standard of care for these patients, its uptake in the U.S. has lagged behind expectations. We used the Health Care Cost Institute (HCCI) database 2008-2017, covering a third of the U.S. employer-sponsored insurance population, to identify early-stage breast cancer patients. Patients were clustered at different geographic levels (Census region, state, core-based statistical area (CBSA), hospital referral region of Dartmouth Atlas, and zip code) and the radiation oncologist level. These two levels are cross-nested. We used a Bayesian cross-classified multilevel logistic model to simultaneously model the geographic units variability and physician-level variability in HF-WBI use across the U.S. Variation metrics included intracluster correlation coefficient (ICC) and median odds ratios (MOR). ICC with a value of 0 is equivalent to MOR of 1, indicating identical outcomes across all levels. After accounting for these variations in the cross-classified multilevel model framework, we evaluated the association between HF-WBI use and clinical and demographic factors.Our study included 79,747 women (74.0%) who underwent CF-WBI and 27,999 (26.0%) who received HF-WBI. HF-WBI adoption increased over time (2008-2017). Variability across radiation oncologists (ICC = 0.272, MOR = 2.88) was notably larger than geographic areas variability. Variability across CBSA (ICC = 0.097, MOR = 1.76) was the strongest among all the geographic levels. The variation in HF-WBI use was mainly attributed to physician-level variability (ICC=0.222, MOR=2.59) based on the cross-classified multilevel model. No substantial differences were found between young (aged 64 or younger with commercial health plans) and older patients (aged 65 or older with Medicare Advantage plans) in terms of both geographic and physician-level variations. After accounting for variability in radiation oncologists and CBSAs, older age, non-reception of chemotherapy, and several community-level factors, including longer distance from home to facility and higher community education level, were associated with a higher likelihood of HF-WBI use. These results may lend insights into potential facilitators/barriers to HF-WBI uptake. Future studies can further investigate the impact of the 2018 American Society for Radiation Oncology (ASTRO) guideline and the Covid-19 pandemic on HF-WBI use, which would illuminate potential improvements of healthcare practices. Citation Format: Yijia Sun, Loren Saulsberry, Chuanhong Liao, Donald Hedeker, Dezheng Huo. Geographic and physician-level variation in the use of hypofractionated radiotherapy for breast cancer in the U.S.: A cross-classified multilevel analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4846.

Geographic and Physician-Level Variation in the Use of Hypofractionated Radiation Therapy for Breast Cancer in the U.S.: A Cross-Classified Multilevel Analysis

We aimed to assess geographic and physician-level variation for hypofractionated whole-breast irradiation (HF-WBI) use for early-stage breast cancer patients in the United States. We further evaluated the association between HF-WBI use and demographic factors after accounting for these variations. We performed a retrospective study of early-stage breast cancer patients using private employer-sponsored insurance claims from 2008 to 2017. Patients were clustered according to geographic level and by radiation oncologist. Bayesian cross-classified multilevel logistic models were used to examine the geographic heterogeneity and variation of radiation oncologists simultaneously. Intracluster correlation coefficient (ICC) and median odds ratios (MOR) were calculated to quantify the variation at different levels. We also used the cross-classified model to identify patient demographic factors associated with receiving HF-WBI. The study included 79,747 women (74.0%) who received conventionally fractionated whole-breast irradiation (CF-WBI) and 27,999 women (26.0%) who underwent HF-WBI. HF-WBI adoption increased significantly across time (2008-2017). The variation in HF-WBI utilization was attributed mostly to physician-level variability (MOR = 2.59). The variability of HF-WBI utilization across core-based statistical areas (CBSAs) (MOR = 1.55) was found to be the strongest among all geographic classifications. After accounting for variability in both CBSAs and radiation oncologists, age, receiving chemotherapy, and several community-level factors, including distance from home to facility, community education level, and racial composition, were found to be associated with HF-WBI utilization. This study demonstrated geographic and physician-level heterogeneity in the use of HF-WBI among early-stage breast cancer patients. HF-WBI utilization was also found to be associated with patient and community-level characteristics. Given observed physician-level variability, intervention through continuing medical education could help doctors to better understand the advantages of HF-WBI and promote the adoption of HF-WBI in the U.S. Influence of physician-level characteristics on HF-WBI utilization merits further study.

Physician Variation and the Impact of Payment Model in Cardiac Imaging.

The influence of fee-for-service reimbursement on cardiac imaging has not been compared with other payment models. Furthermore, variation in ordering practices is not well understood. This retrospective, population-based cohort study using linked administrative data from Alberta, Canada included adults with chronic heart disease (atrial fibrillation, coronary artery disease, and heart failure) seen by cardiac specialists for a new outpatient consultation April 2012 to December 2018. Generalized linear mixed-effects models estimated the association of payment model (including the ability to bill to interpret imaging tests) and the use of cardiac imaging and quantified variation in cardiac imaging. Among 31 685 adults seen by 308 physicians at 136 sites, patients received an observed mean of 0.67 (95% CI, 0.67-0.68) imaging tests per consultation. After adjustment, patients seeing fee-for-service physicians had 2.07 (95% CI, 1.68-2.54) and fee-for-service physicians with ability to interpret had 2.87 (95% CI, 2.16-3.81) times the rate of receiving a test than those seeing salaried physicians. Measured patient, physician, and site effects accounted for 31% of imaging variation and, following adjustment, reduced unexplained site-level variation 40% and physician-level variation 29%. We identified substantial variation in the use of outpatient cardiac imaging related to physician and site factors. Physician payment models have a significant association with imaging use. Our results raise concern that payment models may influence cardiac imaging practice. Similar methods could be applied to identify the source and magnitude of variation in other health care processes and outcomes.

Data-driven approach to identifying potential laboratory overuse in general internal medicine (GIM) inpatients

BackgroundReducing laboratory test overuse is important for high quality, patient-centred care. Identifying priorities to reduce low value testing remains a challenge.ObjectiveTo develop a simple, data-driven approach to identify potential sources...

Ad Hoc Percutaneous Coronary Intervention in Stable Patients With Multivessel or Unprotected Left Main Disease

BackgroundThere is very little information about the use of ad hoc percutaneous coronary intervention (PCI) in stable patients with multivessel (MV) disease or unprotected left main (LM) disease patients for whom a heart team approach is recommended. ObjectiveTo identify the extent of ad hoc PCI utilization for patients with multivessel disease or left main disease, and to explore the inter-hospital variation in ad hoc PCI utilization for those patients. MethodsNew York State’s cardiac registries were used to examine the use and variation in use of ad hoc PCI for MV/LM disease as a percentage of all MV/LM PCIs and revascularizations (PCIs plus coronary artery bypass graft procedures) during 2018 to 2019 in New York. ResultsAfter exclusions, 6,425 of the 8,196 stable PCI patients with MV/LM disease (78.4%) underwent ad hoc PCI, ranging from 58.7% for patients with unprotected LM disease to 85.4% for patients with 2-vessel proximal left anterior descending (PLAD) disease. Ad hoc PCIs comprised 35.1% of all revascularizations, ranging from 11.5% for patients with unprotected LM disease to 63.9% for patients with 2-vessel PLAD disease. The risk-adjusted utilization of ad hoc PCI as a percentage of all revascularizations varied widely among hospitals (eg, from 15% in the first quartile to 46% in the last quartile for 3-vessel disease). ConclusionsAd hoc PCIs occur frequently even among patients with MV/LM disease. This is particularly true among patients with 2-vessel PLAD disease. The frequency of ad hoc PCIs is lower but still high among patients with diabetes and low ejection fraction and higher in hospitals without surgery on-site (SOS). Given the magnitude of hospital- and physician-level variation in the use of ad hoc PCIs for such patients, consideration should be given to a systems approach to achieving heart team consultation and shared decision making that is consistent for SOS and non-SOS hospitals.

Between-Hospital and Between-Physician Variation in Outcomes and Costs in High- and Low-Complex Surgery: A Nationwide Multilevel Analysis

ObjectivesClinicians and policy makers are increasingly exploring strategies to reduce unwarranted variation in outcomes and costs. Adequately accounting for case mix and better insight into the levels at which variation exists is crucial for such strategies. This nationwide study investigates variation in surgical outcomes and costs at the level of hospitals and individual physicians and evaluates whether these can be reliably compared on performance. MethodsVariation was analyzed using 92 330 patient records collected from 62 Dutch hospitals who underwent surgery for colorectal cancer (n = 6640), urinary bladder cancer (n = 14 030), myocardial infarction (n = 31 870), or knee osteoarthritis (n = 39 790) in the period 2018 to 2019. Multilevel regression modeling with and without case-mix adjustment was used to partition variation in between-hospital and between-physician components for in-hospital mortality, intensive care unit admission, length of stay, 30-day readmission, 30-day reintervention, and in-hospital costs. Reliability was calculated for each treatment-outcome combination at both levels. ResultsAcross outcomes, hospital-level variation relative to total variation ranged between ≤ 1% and 15%, and given the high caseloads, this typically yielded high reliability (> 0.9). In contrast, physician-level variation components were typically ≤ 1%, with limited opportunities to make reliable comparisons. The impact of case-mix adjustment was limited, but nonnegligible. ConclusionsIt is not typically possible to make reliable comparisons among physicians due to limited partitioned variation and low caseloads. Nevertheless, for hospitals, the opposite often holds. Although variation-reduction efforts directed at hospitals are thus more likely to be successful, this should be approached cautiously, partly because level-specific variation and the impact of case mix vary considerably across treatments and outcomes.

Rates of Intracoronary Imaging Optimization in Contemporary Percutaneous Coronary Intervention: A Report From the BMC2 Registry.

Intracoronary imaging (ICI) during percutaneous coronary intervention (PCI) improves outcomes, yet hospital- and physician-level variabilities in ICI and its impact on ICI use in contemporary PCI remain unknown. This study was performed to evaluate hospital- and physician-level use of ICI to optimize PCI. Using data from a large statewide registry, patients undergoing PCI between July 2019 and March 2021 were studied. The primary measure of interest was ICI (intravascular ultrasound or optical coherence tomography) optimization during PCI. A fitted hierarchical Bayesian model identified variables independently associated with ICI optimization. The performing hospital and physician were included as random effects in the model. Among 48 872 PCIs, ICI optimization was performed in 8094 (16.6%). Median [interquartile range] hospital- and physician-level frequencies of ICI were 8.8% [3.1%, 16.0%] and 6.1% [1.1%, 25.0%], respectively. Bayesian modeling identified left main PCI (adjusted odds ratio [aOR], 4.41; 95% credible interval [3.82, 5.10]), proximal left anterior descending artery PCI (aOR, 2.28 [2.00, 2.59]), PCI for in-stent restenosis (aOR, 1.55 [1.40, 1.72]), and surgical consult prior to PCI (aOR, 1.21 [1.07, 1.37]) as independent predictors of ICI optimization. The hospital-level median odds ratio, an estimate of the contribution of inter-hospital variability in odds of ICI use, was 3.48 (2.64, 5.04). Physician-level median odds ratio was 3.81 (3.33, 4.45). Substantial hospital- and physician-level variation in ICI was observed. Except for performance of left main PCI, the hospital and physician performing the PCI were more strongly associated with ICI optimization than any patient or procedural factors.

Physician-level variation in axillary surgery in older adults with T1N0 hormone receptor–positive breast cancer.

284 Background: Randomized controlled trial data support safe omission of axillary surgery in patients >70 years old with T1N0 hormone receptor-positive (HR+) breast cancer, but utilization of axillary surgery in the U.S. remains > 80%. We sought to assess the proportion of variance in axillary surgery receipt that is attributable to surgeon-level differences vs. patient level differences, and assess the patient- and surgeon-level factors that affect axillary surgery receipt in this population. Methods: Women >70 years old with T1N0 HR+/HER2-negative breast cancer diagnosed from 2013-2015 in SEER-Medicare were linked to surgeon-level data from the American Medical Association Masterfile. Patients of low-volume surgeons (surgeons treating < 5 patients in this population over the study period) were excluded. To assess patient-and surgeon-level factors associated with axillary surgery receipt, we estimated hierarchical logistic regression models regressing receipt of axillary surgery on surgeon-specific random intercepts (null model). We then re-estimated this model including patient factors (age, Charlson Comorbidity Index (CCI), and a validated claims-based frailty index). Our final model included other surgeon-, patient-, and disease-level factors. The intracluster correlation (ICC) was used to estimate the proportion of total variance in the outcome attributable to the surgeon level. Results: Of 4,410 women included, 58.3% were >75 years old, 20.7% were frail, and 13.9% had a CCI>2; 86.1% of women underwent axillary surgery. Of 432 surgeons represented, 52.6% were female and 9.5% identified as surgical oncologists. In the null model, 10.5% of the variance in the axillary evaluation was attributable to the surgeon-level, with 89.5% attributable to patient-level differences (Table). Adjusting for key patient-level variables (age, CCI, and frailty status) reduced unexplained patient-level variance, resulting in a greater proportion of total unexplained variance attributable to the surgeon level (13%). In our final model, physician subspecialty and years in practice were non-significant, but patients of female surgeons were less likely to undergo axillary surgery (OR 0.69, 95% CI [0.51-0.95]). Conclusions: In older women with T1N0 HR+ disease, patient-level differences reassuringly account for most of the variation in receipt of axillary surgery. Drivers of residual patient-level variation may include unmeasured factors such as differences in surgeon-patient communication and patient preferences.[Table: see text]

Quality and variation of care for chronic kidney disease in Swiss general practice: A retrospective database study.

Chronic kidney disease (CKD) is a common condition in general practice. Data about quality and physician-level variation of CKD care provided by general practitioners is scarce. In this study, we evaluated determinants and variation of achievement of 14 quality indicators for CKD care using electronic medical records data from Swiss general practice during 2013-2019. We defined two patient cohorts from 483 general practitioners, one to address renal function assessment in patients with predisposing conditions (n = 47,201, median age 68 years, 48.7% female) and one to address care of patients with laboratory-confirmed CKD (n = 14,654, median age 80 years, 57.5% female). We investigated quality indicator achievement with mixed-effect logistic regression and expressed physician-level variation as intraclass correlation coefficients (ICCs) and range odds ratios (rORs). We observed the highest quality indicator achievement rate for withholding non-steroidal anti-inflammatory drug prescription in patients with CKD staged G2-3b within 12 months of follow-up (82.6%), the lowest for albuminuria assessment within 18 months of follow-up (18.1%). Highest physician-level variation was found for renal function assessment during 18 months of follow-up in patients with predisposing conditions (diabetes: ICC 0.31, rOR 26.5; cardiovascular disease: ICC 0.28, rOR 17.4; hypertension: ICC 0.24, rOR 17.2). This study suggests potentially unwarranted variation in general practice concerning RF assessment in patients affected by conditions predisposing for CKD. We further identified potential gaps in quality of CKD monitoring as well as lower quality of CKD care for female patients and patients not affected by comorbidities.

A novel approach to attribute responsible physicians using inpatient claims.

More robust attribution methods are necessary to understand physician-level variation in quality of care across risk-adjusted inpatient measures. We address a gap in the literature involving attribution of physicians to inpatient stays using administrative claims data, in which rule-based methods often inadequately attribute physicians. Methodology comparison study using a cross-section of inpatient stays. A novel approach is proposed in which physicians' relative degrees of responsibility for inpatient stays are expressed through physician-specific attribution ratios informed by existing patient characteristics and comorbidities. Attribution results are compared with the rule-based benchmark method for 7 CMS-defined clinical cohorts, including a COVID-19 cohort. Using 6,835,460 unique patient encounters during 2020 (n = 136,339 in out-of-sample cohort), the proposed approach favored specialists generally considered responsible for primary clinical conditions when compared with the benchmark. The most salient shift within the acute myocardial infarction (+17.0%), heart failure (+20.2%), and coronary artery bypass graft (+4.0%) cohorts was toward the cardiovascular diseases specialty, and the chronic obstructive pulmonary disease (+24.0%) and pneumonia (+16.2%) cohorts resulted in a shift toward the pulmonary diseases specialty. The COVID-19 cohort resulted in considerable shifts toward infectious diseases and pulmonary diseases specialties (+17.4% and +14.1%, respectively). The stroke cohort experienced a considerable shift toward the neurology specialty (+42.2%). We provide a robust method to attribute physicians to patients, which is a necessary tool to understand physician-level variation in quality of care within the inpatient acute care setting. The proposed method provides consistency across facilities and eliminates unattributed patients resulting from unsatisfied business rules.

Association of Physician Characteristics With Early Adoption of Virtual Health Care

The rapid transition to virtual health care has depended on physician and patient abilities to adopt new technology and workflows. Physicians transitioning more slowly or not at all could result in access challenges for their patients. To identify physician characteristics associated with the transition to virtual health care in a large regional health care system. This retrospective cross-sectional study uses administrative health system databases to analyze data from all 3473 physicians providing ambulatory care through a large New England health care system, which includes 12 hospitals and their ambulatory practices, from October 1, 2019, through December 31, 2020. Physicians characterized based on gender, popularized generational demographic cohort (Silent Generation, born 1928-1945; Baby Boomers, born 1946-1964; Generation X, born 1965-1980; and Millennials, born 1981-1996), specialty (behavioral health, primary care, medical, and surgical), and hospital affiliation as well as selected patient characteristics (number of visits and proportion of patients with self-pay or Medicaid insurance, aged 65 years or older, preference for speaking a language other than English, from a racial or ethnic minority group, and with an active patient portal). Early adoption of virtual health care. Bivariate comparisons were made, and regression modeling was used to examine characteristics associated with the likelihood of early adoption of virtual health care. Of 3473 physicians conducting ambulatory visits during the study period, 1624 (46.8%) were women, 83 (2.4%) were in the Silent Generation, 994 (28.6%) were Baby Boomers, 1637 (47.1%) were in Generation X, and 759 (21.9%) were Millennials. There were 1649 physicians (47.5%) in medical specialties, 749 physicians (21.6%) in surgical specialties, and 248 physicians (7.1%) in behavioral health. After accounting for other characteristics, female (odds ratio [OR], 1.23; 95% CI, 1.06-1.44), behavioral health (OR, 2.92; 95% CI, 2.11-4.04), and primary care (OR, 1.69; 95% CI, 1.36-2.09) physicians had greater odds of being early adopters, and physicians in the Silent Generation (OR, 0.39, 95% CI, 0.24-0.65) and in surgical specialties (OR, 0.46; 95% CI, 0.38-0.57) were less likely to be early adopters. Patient characteristics were less strongly associated with physician adoption. In this cross-sectional study, there was physician-level variation in the adoption of virtual health care, with female, primary care, and behavioral health physicians in this system most likely to lead the transformation to virtual health care.

Adoption of Ultrahypofractionated Radiation Therapy in Patients With Breast Cancer

IntroductionThe first high-quality clinical trial to support ultrahypofractionated whole-breast irradiation (ultra-HF-WBI) for invasive early-stage breast cancer (ESBC) was published in April 2020, coinciding with the beginning of the COVID-19 pandemic. We analyzed adoption of ultra-HF-WBI for ductal carcinoma in situ (DCIS) and ESBC at our institution after primary trial publication. Methods and MaterialsWe evaluated radiation fractionation prescriptions for all patients with DCIS or ESBC treated with WBI from March 2020 to May 2021 at our main campus and regional campuses. Demographic and clinical characteristics were extracted from the electronic medical record. Treating physician characteristics were collected from licensure data. Hierarchical logistic regression models identified factors correlated with adoption of ultra-HF-WBI (26 Gy in 5 daily factions [UK-FAST-FORWARD] or 28.5 Gy in 5 weekly fractions [UK-FAST]). ResultsOf 665 included patients, the median age was 61.5 years, and 478 patients (71.9%) had invasive, hormone-receptor-positive breast cancer. Twenty-one physicians treated the included patients. In total, 249 patients (37.4%) received ultra-HF-WBI, increasing from 4.3% (2 of 46) in March-April 2020 to a high of 45.5% (45 of 99) in July-August 2020 (P < .001). Patient factors associated with increased use of ultra-HF-WBI included older age (≥50 years old), low-grade WBI without inclusion of the low axilla, no radiation boost, and farther travel distance (P < .03). Physician variation accounted for 21.7% of variance in the outcome, with rate of use of ultra-HF-WBI by the treating physicians ranging from 0% to 75.6%. No measured physician characteristics were associated with use of ultra-HF-WBI. ConclusionsAdoption of ultra-HF-WBI at our institution increased substantially after the publication of randomized evidence supporting its use. Ultra-HF-WBI was preferentially used in patients with lower risk disease, suggesting careful selection for this new approach while long-term data are maturing. Substantial physician-level variation may reflect a lack of consensus on the evidentiary standards required to change practice.

Physician Influence on Variation in Receipt of Aggressive End-of-Life Care Among Women Dying of Ovarian Cancer.

End-of-life care for women with ovarian cancer is persistently aggressive, but factors associated with overuse are not well understood. We evaluated physician-level variation in receipt of aggressive end-of-life care and examined physician-level factors contributing to this variation in the SEER-Medicare data set. Medicare beneficiaries with ovarian cancer who died between 2000 and 2016 were included if they were diagnosed after age 66 years, had complete Medicare coverage between diagnosis and death, and had outpatient physician evaluation and management for their ovarian cancer. Using multilevel logistic regression, we examined physician variation in no hospice enrollment, late hospice enrollment (≤ 3 days), > 1 emergency department visit, an intensive care unit stay, terminal hospitalization, > 1 hospitalization, receiving a life-extending or invasive procedure, and chemotherapy (in the last 2 weeks). In this sample of 6,288 women, 51% of women received at least one form of aggressive end-of-life care. Most common were no hospice enrollment (28.9%), an intensive care unit stay (18.6%), and receipt of an invasive procedure (20.7%). For not enrolling in hospice, 9.9% of variation was accounted for by physician clustering (P < .01). Chemotherapy had the highest physician variation (12.4%), with no meaningful portion of the variation explained by physician specialty, volume, region, or patient characteristics. In this study, a meaningful amount of variation in aggressive end-of-life care among women dying of ovarian cancer was at the physician level, suggesting that efforts to improve the quality of this care should include interventions aimed at physician practices and decision making in end-of-life care.

Analysis of Consistency in Emergency Department Physician Variation in Propensity for Admission Across Patient Sociodemographic Groups

Sociodemographic disparities in health care and variation in physician practice patterns have been well documented; however, the contribution of variation in individual physician care practices to health disparities is challenging to quantify. Emergency department (ED) physicians vary in their propensity to admit patients. The consistency of this variation across sociodemographic groups may help determine whether physician-specific factors are associated with care differences between patient groups. To estimate the consistency of ED physician admission propensities across categories of patient sex, race and ethnicity, and Medicaid enrollment. This cross-sectional study analyzed Medicare fee-for-service claims for ED visits from January 1, 2016, to December 31, 2019, in a 10% random sample of hospitals. The allocation of patients to ED physicians in the acute care setting was used to isolate physician-level variation in admission rates that reflects variation in physician decision-making. Multi-level models with physician random effects and hospital fixed effects were used to estimate the within-hospital physician variation in admission propensity for different patient sociodemographic subgroups and the covariation in these propensities between subgroups (consistency), adjusting for primary diagnosis and comorbidities. Admission from the ED. The analysis included 4 567 760 ED visits involving 2 334 361 beneficiaries and 15 767 physicians in 396 EDs. The mean (SD) age of the beneficiaries was 78 (8.2) years, 2 700 661 visits (59.1%) were by women, and most patients (3 839 055 [84.1%]) were not eligible for Medicaid. Of 4 473 978 race and ethnicity reports on enrollment, 103 699 patients (2.3%) were Asian/Pacific Islander, 421 588 (9.4%) were Black, 257 422 (5.8%) were Hispanic, and 3 691 269 (82.5%) were non-Hispanic White. Within hospitals, adjusted rates of admission were higher for men (36.8%; 95% CI, 36.8%-36.9%) than for women (33.7%; 95% CI, 33.7%-33.8%); higher for non-Hispanic White (36.0%; 95% CI, 35.9%-36.0%) than for Asian/Pacific Islander (33.6%; 95% CI, 33.3%-33.9%), Black (30.2%; 95% CI, 30.0%-30.3%), or Hispanic (31.1%; 95% CI, 30.9%-31.2%) beneficiaries; and higher for beneficiaries dually enrolled in Medicaid (36.3%; 95% CI, 36.2%-36.5%) than for those who were not (34.7%; 95% CI, 34.7%-34.8%). Within hospitals, physicians varied in the percentage of patients admitted, ranging from 22.4% for physicians at the 10th percentile to 47.6% for physicians at the 90th percentile of the estimated distribution. Physician admission propensities were correlated between men and women (r = 0.99), Black and non-Hispanic White patients (r = 0.98), and patients who were dually enrolled and not dually enrolled in Medicaid (r = 0.98). This cross-sectional study indicated that, although overall rates of admission differ systematically by patient sociodemographic factors, an individual physician's propensity to admit relative to other physicians appears to be applied consistently across sociodemographic groups of patients.

Practice variation and trends in the management of incomplete and missed spontaneous abortion: Informing a multisite quality improvement project

Practice variation and trends in the management of incomplete and missed spontaneous abortion: Informing a multisite quality improvement project. Megg Wylie, Amelia Srajer, Kevin Lonergan, Philippa Brain, Eddy Lang Background: Practice variation in the management of spontaneous abortion exists in the Emergency Department (ED). We developed a multisite retrospective study to assess how the management of spontaneous abortion has changed over 2014-2019 across four Calgary EDs, with emphasis on assessing variation and trends between non-operative (medical/expectant) and operative (dilatation and curettage) management. Medical management has been increasingly indicated as effective, yet a knowledge gap exists regarding its use. Knowledge of that proportion and physician-level practice variation will facilitate educational and audit and feedback style initiatives. Results provide justification and supporting data for said initiatives, which may be extrapolated to elsewhere. Implementation: Two medical students are heading the day to day work of this project, with support from a principal investigator with the Department of Emergency Medicine in Calgary. We also have the support of a data manager and the head of pregnancy loss in the region. This study was implemented as a quality improvement project. Therefore, the Conjoint Health Research Ethics Board at the University of Calgary was consulted to ensure the project qualified as a quality improvement and that our privacy protections were appropriate. With approval from the ethics board, we needed the data to analyze and assess. To do so, we utilized Sunrise Clinical Manager (SCM) to retrospectively collect data. Sunrise Clinical Manager, a system utilized in Calgary EDs to track patient and department information, was accessed to collect administrative data. Sustaining this work will involve the continued efforts of the described team, largely in writing up the results and disseminating them via audit and feedback procedures. Evaluation Methods: Using SCM, data were retrospectively collected for patients coded with International Classification of Disease (ICD-10) codes O03.4 (incomplete spontaneous abortion without complication) or O02.1 (missed abortion) who presented to an ED in Calgary (Foothills Medical Centre, Peter Lougheed Centre, South Calgary Hospital, and Rockyview General Hospital) over 2014-2019. We collected patient and environmental factors to allow for the examination of unintended associations. Hemoglobin, HCG level, CTAS code, PIA (time to MD), and U/S result (to confirm diagnosis) were collected. Variables regarding length of stay, procedures received (D&amp;Cs, or other), and returns to care (within 72 hours, and 7 days) were collected. Return to care for future D&amp;C was considered a proxy for failed non-operative management. Demographic and practice data were collected on ED physicians who saw a minimum of 15 patients from our cohort, to gain understanding of trends in practice. Data were analyzed using Chi-square and Mann-Whitney U tests. Results: Within our cohort, 1110 (28.9%) patients received a D&amp;C. The remaining 2735 (71.1%) patients were managed non-operatively. Variation and trends were present between sites, with rates of D&amp;Cs ranging from 15.8% to 33.5% (p &lt;0.001). The rate of D&amp;Cs decreased from 34.2% in 2014 to 22.6% in 2019 across all sites (p &lt;0.001), and 11.6% absolute and 33.9% relative reduction; yet there was minimal variation over time in rates of ED returns and returns resulting in D&amp;Cs. 78.6% of physicians who saw ≥ 15 patients were female, with female physicians responding to 81.8% of our cohort Advice and Lessons Learned:1) Our first suggested lesson is to have a clear plan regarding deadlines and timelines, but toalso have room for flexibility. At some times the work on this project was slowed to alloweffective collaboration with the obstetrics and gyneocology department, or to allow for therefinement of data management. By setting realistic timelines, team members wereencouraged to progress the work in a timely fashion. However, by having flexibility the teamwas able to adapt to roadblocks along the way. 2) A second lesson would be the importance of meaningful collaboration between departments.Though the setting of the project was within Calgary EDs, the topic and content have clearrelevance to obstetics and gynaecology. By consulting with members of the obstetrics andgynaecology department we were able to clarify our objectives and have a betterunderstanding of local contextual factors that influenced our results.

Association Between Attending Physicians' Rates of Referral to Palliative Care and Location of Death in Hospitalized Adults With Serious Illness: A Population-based Cohort Study.

Patients who receive palliative care are less likely to die in hospital. To measure the association between physician rates of referral to palliative care and location of death in hospitalized adults with serious illness. Population-based decedent cohort study using linked health administrative data in Ontario, Canada. A total of 7866 physicians paired with 130,862 hospitalized adults in their last year of life who died of serious illness between 2010 and 2016. Physician annual rate of referral to palliative care (high, average, low). Odds of death in hospital versus home, adjusted for patient characteristics. There was nearly 4-fold variation in the proportion of patients receiving palliative care during follow-up based on attending physician referral rates: high 42.4% (n=24,433), average 24.7% (n=10,772), low 10.7% (n=6721). Referral to palliative care was also associated with being referred by palliative care specialists and in urban teaching hospitals. The proportion of patients who died in hospital according to physician referral rate were 47.7% (high), 50.1% (average), and 52.8% (low). Hospitalized patients cared for by a physician who referred to palliative care at a high rate had lower risk of dying in hospital than at home compared with patients who were referred by a physician with an average rate of referral [adjusted odds ratio 0.91; 95% confidence interval, 0.86-0.95; number needed to treat=57 (interquartile range 41-92)] and by a physician with a low rate of referral [adjusted odds ratio 0.81; 95% confidence interval, 0.77-0.84; number needed to treat =28 patients (interquartile range 23-44)]. An attending physicians' rates of referral to palliative care is associated with a lower risk of dying in hospital. Therefore, patients who are cared for by physicians with higher rates of referral to palliative care are less likely to die in hospital and more likely to die at home. Standardizing referral to palliative care may help reduce physician-level variation as a barrier to access.

Variation In Emergency Department Admission Rates Among Medicare Patients: Does The Physician Matter?

Hospitalizations account for the largest share of health care spending. New payment models increasingly encourage health care providers to reduce hospital admissions. Although emergency department (ED) physicians play a major role in the decision to admit a patient, the extent to which admission rates vary among ED physicians even within the same hospital remains poorly understood. In this study we examined physician-level variation in ED admission rates for Medicare patients. We found meaningful variation in admission rates: The mean physician-level adjusted admission rate was 38.9percent and ranged from 32.2percent to 45.6percent for physicians at the tenth and ninetieth percentiles, respectively, of the estimated distribution within the same hospital. In contrast, the predicted risk for admission based on patient characteristics varied little among these physicians, suggesting that the variation in admission rates was not due to differences in patients seen. Our results suggest that strategies targeting physician decision making could modify (by either increasing or decreasing when appropriate) rates of admissions.

Vital Directions, Quality, And More

From the Editor-In-Chief Health AffairsVol. 40, No. 2: Vital Directions, Quality & More Vital Directions, Quality, And MoreAlan R. WeilPUBLISHED:February 2021Free Accesshttps://doi.org/10.1377/hlthaff.2021.00033AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSQuality of careHealth equityHealth disparitiesRacismMedicaidMedicare AdvantageMedicaid patientsAccess to carePandemicsOut-of-pocket expensesNonprofit statusMortality ratesMortalityMedicare savings programs PhysiciansEmergency departmentsWomen's healthChildren's healthMental healthSubstance use disorderThis month’s issue leads with articles from the National Academy of Medicine’s Vital Directions for Health and Health Care 2021 project, which sets forth priorities for the new administration of President Joe Biden, who took office January 20, 2021.Vital DirectionsVictor Dzau and coauthors identify the overarching theme of the Vital Directions series as “the clear and urgent obligation for the US to turn its full attention to the growing problem of health inequities and to the structural racism that perpetuates such disparities.” Peter Daszak and coauthors review US pandemic preparedness and outline steps to strengthen our ability to anticipate and respond to future pandemics. Elena Fuentes-Afflick and coauthors draw on a life-course framework to identify promising interventions to improve the health of women and children. Terry Fulmer and coauthors identify six strategies to improve care and quality of life for older adults. Margarita Alegría and coauthors describe new models of care that focus on mental health and addiction. William Shrank and coauthors discuss health cost and financing priorities to advance access, affordability, and equity.QualityDavid Meyers and coauthors use data from a natural experiment to quantify the degree to which Medicare Advantage (MA) plans with higher star ratings provide better care. Enrollees in an MA plan with one more star were 3.4 percent more likely to use a higher-rated hospital and 2.6 percent less likely to be readmitted within ninety days of discharge.Peter Smulowitz and coauthors describe physician-level variation in emergency department admission rates for Medicare fee-for-service patients. Within-hospital admission rates range from 32.2 to 45.6 percent for physicians at the tenth and ninetieth percentiles, leading the authors to conclude that there is “substantial variation in rates of admissions among physicians at the same hospital that is not related to observable patient characteristics.”Fabian Duarte and coauthors show that the reduction in the rate of uninsurance among adults ages 60–64 due to the Affordable Care Act greatly increased rates of cancer detection for this population. Fifty-nine additional incidents of cancer were detected per 100,000 people, and 68 percent of these were early- and middle-stage cancers—and thus more likely treatable.EquityAll-cause mortality rates increased dramatically in 2020 because of coronavirus disease 2019 (COVID-19). Maria Polyakova and coauthors show that excess mortality in April 2020 was much higher for Blacks than for Whites and that racial and ethnic disparities varied significantly by state.Rishi Wadhera and coauthors analyze all-cause mortality rates for rural and urban Medicare beneficiaries dually enrolled in Medicaid from 2004 to 2017. Although all-cause mortality declined for both groups across the study period, rates were higher among rural beneficiaries (92.8 per 1,000) than among their urban counterparts (75.1 per 1,000).Lisa Iezzoni and coauthors surveyed US physicians about their perceptions of care for people with disability. Only 40.7 percent of respondents were “very confident” they could “provide the same quality of care” to patients with disability as to patients without disability.This month, Health Affairs launches our own equity initiative. Please keep an eye out for more information on the Health Affairs Blog.Access To CareIn 2012 the South Carolina Medicaid program began paying for long-acting reversible contraceptive (LARC) separately from the global maternity payment. Maria Steenland and coauthors find that this increased immediate postpartum LARC use among adolescents by 0.19 percentage points per month.Johanna Catherine Maclean and coauthors find that Medicaid acceptance by residential substance use disorder treatment facilities increased in states that received Institutions for Mental Diseases waivers by 19 percent in the first year and 34 percent in the second year.Tamara Beetham and coauthors audited 368 residential addiction treatment programs in the US. They find that 65 percent of for-profit programs use one or more aggressive recruitment techniques compared with only 9 percent of nonprofit programs.Steven Chen and coauthors analyze commercial health insurance claims in 2017 and find that “nearly 40 percent of commercially insured people incurred half of their annual out-of-pocket spending in just one encounter, and 26 percent incurred 90 percent of their annual out-of-pocket spending in only one or two encounters.”AcknowledgmentsHealth Affairs thanks the Gordon and Betty Moore Foundation, The John A. Hartford Foundation, the National Academy of Medicine, and the Robert Wood Johnson Foundation for their financial support of publication of the Vital Directions articles in this issue. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 1 February 2021 Information© 2021 Project HOPE—The People-to-People Health Foundation, Inc.PDF download